Can clinical scoring systems improve the diagnostic accuracy in patients with suspected adult appendicitis and equivocal preoperative computed tomography findings?

OBJECTIVE: Adult appendicitis (AA) with equivocal computed tomography (CT) findings remains a diagnostic challenge for physicians. Herein we evaluated the diagnostic performance of several clinical scoring systems in adult patients with suspected appendicitis and equivocal CT findings. METHODS: We retrospectively evaluated 189 adult patients with equivocal CT findings. Alvarado, Eskelinen, appendicitis inflammatory response, Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), and adult appendicitis score (AAS) scores were evaluated, receiver operating characteristic analysis was conducted, and the optimal, low, and high cut-off values were determined for patient classification into three groups: low, intermediate, or high. RESULTS: In total, 61 patients were included in the appendicitis group and 128 in the non-appendicitis group. There were no significant differences between the area under the curve of the clinical scoring systems in the final diagnosis of AA for equivocal appendicitis on CT (Alvarado, 0.698; Eskelinen, 0.710; appendicitis inflammatory response, 0.668; RIPASA, 0.653; AAS, 0.726). A RIPASA score greater than 7.5 had a high positive predictive value (90.9) and an AAS score less than or equal to 5 had a high negative predictive value (91.7) in the diagnosis of AA. CONCLUSION: The accuracy of clinical scoring systems in the diagnosis of AA with equivocal CT findings was moderate. Therefore, a high RIPASA score may assist in the diagnosis of AA in patients with equivocal CT findings, and a low AAS score may be used as a criterion for patient discharge. Most patients presented with intermediate scores. The patients with equivocal CT findings may be considered as a third diagnostic category of AA.

Randomized, noninferiority study between video versus hand ultrasound with wet foam dressing materials to simulate B-lines in lung ultrasound: A CONSORT-compliant article.

BACKGROUND: This study evaluated the efficacy of a teaching method using simulated B-lines of hand ultrasound with a wet foam dressing material. METHODS: This prospective, randomized, noninferiority study was conducted on emergency medical technician students without any relevant training in ultrasound. Following a lecture including simulated (SG) or real video clips (RG) of B-lines, a posttest was conducted and a retention test was performed after 2 months. The test consisted of questions about B-lines in 40 randomly mixed video clips (20 simulated and 20 real videos) with 4 answer scores (R-1 [the correct answer score for the real video clips] vs S-1 [the correct answer score for the simulated video clips] in the posttest, R-2 [the correct answer score for the real video clips] vs S-2 [the correct answer score for the simulated video clips] in the retention test). RESULTS: A total of 77 and 73 volunteers participated in the posttest (RG, 38; SG, 39) and retention test (RG, 36; SG, 37), respectively. There was no significant (P > .05) difference in scores of R-1, S-1, R-2, or S-2 between RG and SG. The mean score differences between RG and SG were -0.6 (95% confidence interval [CI]: -1.49 to 0.11) in R-1, -0.1 (95% CI: -1.04 to 0.86) in S-1, 0 (95% CI: -1.57 to 1.50) in R-2, and -0.2 (95% CI: -1.52 to 0.25) in S-2. The mean differences and 95% CIs for all parameters fell within the noninferiority margin of 2 points (10%). CONCLUSION: Simulated B-lines of hand ultrasound with a wet foam dressing material were not inferior to real B-lines. They were effective for teaching and simulations. TRIAL REGISTRATION: The study was registered with the Clinical Trial Registry of Korea: https://cris.nih.go.kr/cris/index.jsp (KCT0002144).

Does the use of bedside ultrasonography reduce emergency department length of stay for patients with renal colic?: a pilot study.

OBJECTIVE: The aim of this study was to evaluate the effect of adding bedside ultrasonography to the diagnostic algorithm for nephrolithiasis on emergency department (ED) length of stay. METHODS: A prospective, randomized, controlled pilot study was conducted from October 2014 to December 2014 with patients with acute flank pain. In the non-ultrasonography group (NUSG), non-contrast computed tomography was selected based on clinical features and hematuria in the urinalysis. In the ultrasonography group (USG), non-contrast computed tomography was selected based on clinical features and hydronephrosis on bedside ultrasonography. The primary outcome was ED length of stay. The secondary outcomes were radiation exposure, amount of analgesics, proportion of patients with diseases other than ureteral calculus, and proportion of patients with unexpected ED revisits within 7 days from the index visit. RESULTS: A total of 103 patients were enrolled (NUSG, 51; USG, 52). The ED length of stay for the USG (89.0 minutes) was significantly shorter than that for the NUSG (163.0 minutes, P<0.001). There were no significant differences between the two groups in the radiation exposure dose (5.29 and 5.08 mSv, respectively; P=0.392), amount of analgesics (P=0.341), proportion of patients with diseases other than ureteral calculus (13.0% and 6.8%, respectively; P=0.486), and proportion of patients with unexpected ED revisits within 7 days from the index visit (7.8% and 9.6%, respectively; P=1.000). CONCLUSION: The use of early bedside ultrasonography for patients with acute flank pain could reduce the ED length of stay without increasing unexpected ED revisits.

Evaluation of a novel simulation method of teaching B-lines: hand ultrasound with a wet foam dressing material.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of teaching A- and B-lines, and lung sliding with a novel simulation methods using hand ultrasound. METHODS: All subjects enrolled were medical school students who were novices in lung ultrasound. All subjects attended a 20-minute lecture about lung ultrasound using simulated video clips of A-lines, B-lines, and lung sliding; and then a 20-minute post-test was administered. The post-test included questions on the presence or absence of A-lines, B-lines, and lung sliding using a random mixture of 20 real video clips and 20 simulated video clips created by using hand ultrasound with or without foam dressing materials. A Wilcoxon signed rank test was used to compare the scores of A-lines, B-lines, and lung sliding between the real images (RG) and simulated models (SG). RESULTS: There was a statistically significant difference in the median score of the correct answers for A-lines (RG, 18; SG, 17; P=0.037). Correct answers for B-line were significantly different between RG and SG group (RG, 18; SG, 17; P=0.008). There was a statistically significant difference in the median score of the correct answers for lung sliding (RG, 16; SG, 18; P<0.001). CONCLUSION: We found this novel B-line teaching model by using a hand ultrasound with a wet foam dressing material is effective for beginners who are less experienced with lung ultrasound and pulmonary interstitial syndrome.

Performance of intubation with 4 different airway devices by unskilled rescuers: manikin study.

INTRODUCTION: This study was designed to compare the performances of 4 airway devices in achieving successful ventilation. METHODS: A randomized crossover trial was conducted to evaluate 4 airway devices: laryngeal mask airway (LMA), i-gel (iGEL), PENTAX Airway Scope (AWS), and Macintosh laryngoscope (MCL). Thirty-eight unskilled rescuers performed intubation on a manikin during chest compressions in normal and difficult airway scenarios. The time to ventilation, intubation success rate, and difficulty of intubation were measured. RESULTS: The time to ventilation of the airway devices in the normal scenario had a median value of 8.8 seconds (interquartile range, 7.3-10.5 seconds) for iGEL, 16.1 seconds (13.9-19.3 seconds) for LMA, 30.6 seconds (24.6-37.6 seconds) for AWS, and 35.0 seconds (29.5-45.9 seconds) for MCL. In the difficult airway scenario, the respective time to ventilation was 8.6 seconds (7.8-10.0 seconds), 15.3 seconds (14.3-20.2 seconds), 29.4 seconds (25.7-36.3 seconds) and 59.0 seconds (46.1-103.3 seconds). The success rates were 100% and 100% for LMA, 100% and 100% for iGEL, 97.4% and 94.7% for AWS, and 78.9% and 47.4% for MCL in the normal and difficult airway scenarios. The difficulties of intubation expressed as numerical rating scale were 2.0 and 2.0 (median values) for LMA, 1.0 and 2.0 for iGEL, 3.0 and 3.0 for AWS, and 4.0 and 5.0 for MCL in the normal and difficult airway scenarios, respectively. CONCLUSION: With novice intubators who were unfamiliar with the airway devices, the LMA, iGEL, and AWS were superior to the MCL for establishing an airway without interruption of chest compressions in a manikin study. Intubation with the iGEL was faster and easier than with the other airway devices.

Early hyperoxemia may not increase mortality after cardiac arrest: a pilot study.

OBJECTIVE: International Liaison Committee on Resuscitation guidelines advocate an arterial saturation of 94% to 96% after return of spontaneous circulation (ROSC). However, a few clinical trials have investigated the impact of postresuscitative O2 therapy after cardiac arrest. We studied whether early hyperoxemia is associated with a poor post-ROSC outcome after in-hospital cardiac arrest. METHODS: We retrospectively reviewed patients who experienced an in-hospital cardiac arrest from January 2005 to January 2011. Based on the results of the first arterial blood gas analysis (ABGA) within 10 minutes and a second ABGA from 60 to 120 minutes after ROSC, patients were classified into three groups: hyperoxemia (PaO2 ≥ 300 mmHg), normoxemia (300 mmHg > PaO2 ≥ 60 mmHg), and hypoxemia (PaO2 < 60 mmHg or ratio of PaO2 to fraction of inspired oxygen < 300). We examined whether early hyperoxemia was associated with survival and neurological outcome. RESULTS: There were 792 patients who met the inclusion criteria: 638 (80.6%) in the hypoxemia group, 62 (7.8%) in the normoxemia group, and 92 (11.6%) in the hyperoxemia group. Multiple logistic regression analysis showed that hyperoxemia was not associated with survival (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.30 to 3.84) or neurological outcome (OR, 1.03; 95% CI, 0.31 to 3.40). CONCLUSION: Postresuscitation hyperoxemia was not associated with survival or neurological outcome in patients with ROSC after in-hospital cardiac arrest.

Heart rate-corrected QT interval predicts mortality in glyphosate-surfactant herbicide-poisoned patients.

BACKGROUND: Glyphosate-surfactant herbicide is promoted by the manufacturer as having no risks to human health. Glyphosate surfactant has recently been used with increasing frequency in suicide attempts, so clinical toxicologists occasionally encounter cases of severe systemic toxicity. The purpose of this study was to identify the early predictive factors of patients at risk for mortality and the usefulness of the corrected QT interval (QTc interval) for predicting mortality from glyphosate-surfactant intoxication. METHODS: This was a retrospective cohort study conducted from January 2005 to December 2012. A total of 153 patients with acute glyphosate-surfactant ingestion were included. To identify the predictive factors for mortality, objective variables easily assessed at presentation including previously reported predictive factors for mortality and severity were retrospectively analyzed for their association with mortality using univariate and multiple logistic analyses. RESULTS: The average age of the patients was 56 years (range, 19-93 years). Of the 153 patients, 19 (12.4%) died. The most common abnormal electrocardiogram findings were prolonged QTc interval followed by intraventricular conduction delay and first-degree atrioventricular block. Nonsurvivors had a significantly more prolonged QTc interval when compared with that of survivors (survivors: 453.4 ± 33.6 milliseconds vs nonsurvivors: 542 ± 32.0 milliseconds, P < .001). Corrected QT interval and age were associated with a significantly increased risk of death in a multiple logistic regression. In a receiver operating curve analysis, the QTc interval had significant discriminatory power. CONCLUSION: Prolonged QTc interval seems to be a useful prognostic factor for mortality in patients intoxicated with glyphosate-surfactant herbicide.

The most effective rescuer's position for cardiopulmonary resuscitation provided to patients on beds: a randomized, controlled, crossover mannequin study.

BACKGROUND: The effectiveness of chest compressions for cardiopulmonary resuscitation (CPR) is affected by the rescuer's position with respect to the patient. In hospitals, chest compressions are typically performed while standing beside the patient, who is placed on a bed. STUDY OBJECTIVES: To compare the effectiveness of chest compressions, performed on a bed during 2 min of CPR, among three different rescuer positions: standing, on a footstool, or kneeling on the bed. METHODS: We performed a crossover randomized simulation trial. Participants were recruited from among students in the Department of Paramedics from July to August 2011. Thirty-eight participants were enrolled, and they performed chest compressions on a mannequin for 2 min in each of the three different positions, with a 1-week interval between each position. RESULTS: The number of adequate compressions (depth > 50 mm) and the mean compression depth were significantly greater in the kneeling and footstool positions than in the standing position, but there was no significant difference between the kneeling and footstool positions. There were no significant differences in the compression rate, the percentage of correctly released compressions, and the percentage of compressions performed using the correct hand position among the three rescuer positions. CONCLUSION: The mean compression depth and the number of adequate compressions were greater for both the kneeling and footstool positions than for the standing position during 2 min of CPR. We recommend kneeling on a bed or standing on a footstool as the rescuer positions during hospital CPR on a bed.

Performance assessment of the SOFA, APACHE II scoring system, and SAPS II in intensive care unit organophosphate poisoned patients.

This study assessed the ability of the Sequential Organ Failure Assessment (SOFA) and Acute Physiology, Chronic Health Evaluation (APACHE) II scoring systems, as well as the Simplified Acute Physiology Score (SAPS) II method to predict group mortality in intensive care unit (ICU) patients who were poisoned with organophosphate. The medical records of 149 organophosphate poisoned patients admitted to the ICU from September 2006 to December 2012 were retrospectively examined. The SOFA, APACHE II, and SAPS II were calculated based on initial laboratory data in the Emergency Department, and during the first 24 hr of ICU admission. The probability of death was calculated for each patient based on the SOFA score, APACHE II score, and SAPS II equations. The ability to predict group mortality by the SOFA score, APACHE II score, and SAPS II method was assessed using two by two decision matrices and receiver operating characteristic (ROC) curve analysis. A total of 131 patients (mean age, 61 yr) were enrolled. The sensitivities, specificities, and accuracies were 86.2%, 82.4%, and 83.2% for the SOFA score, respectively; 65.5%, 68.6%, and 67.9% for the APACHE II scoring system, respectively; and 86.2%, 77.5%, and 79.4% for the SAPS II, respectively. The areas under the curve in the ROC curve analysis for the SOFA score, APACHE II scoring system, and SAPS II were 0.896, 0.716, and 0.852, respectively. In conclusion, the SOFA, APACHE II, and SAPS II have different capability to discriminate and estimate early in-hospital mortality of organophosphate poisoned patients. The SOFA score is more useful in predicting mortality, and easier and simpler than the APACHE II and SAPS II.

Efficacy of metronome sound guidance via a phone speaker during dispatcher-assisted compression-only cardiopulmonary resuscitation by an untrained layperson: a randomised controlled simulation study using a manikin.

AIM: Untrained laypersons should perform compression-only cardiopulmonary resuscitation (COCPR) under a dispatcher's guidance, but the quality of the chest compressions may be suboptimal. We hypothesised that providing metronome sounds via a phone speaker may improve the quality of chest compressions during dispatcher-assisted COCPR (DA-COCPR). METHODS: Untrained laypersons were allocated to either the metronome sound-guided group (MG), who performed DA-COCPR with metronome sounds (110 ticks/min), or the control group (CG), who performed conventional DA-COCPR. The participants of each group performed DA-COCPR for 4 min using a manikin with Skill-Reporter, and the data regarding chest compression quality were collected. RESULTS: The data from 33 cases of DA-COCPR in the MG and 34 cases in the CG were compared. The MG showed a faster compression rate than the CG (111.9 vs 96.7/min; p=0.018). A significantly higher proportion of subjects in the MG performed the DA-COCPR with an accurate chest compression rate (100-120/min) compared with the subjects in the CG (32/33 (97.0%) vs 5/34 (14.7%); p<0.0001). The mean compression depth was not different between the MG and the CG (45.9 vs 46.8 mm; p=0.692). However, a higher proportion of subjects in the MG performed shallow compressions (compression depth <38 mm) compared with subjects in the CG (median % was 69.2 vs 15.7; p=0.035). CONCLUSIONS: Metronome sound guidance during DA-COCPR for the untrained bystanders improved the chest compression rates, but was associated more with shallow compressions than the conventional DA-COCPR in a manikin model.

The difference in C-reactive protein value between initial and 24 hours follow-up (D-CRP) data as a predictor of mortality in organophosphate poisoned patients.

BACKGROUND: Organophosphate poisoning is a worldwide concern and there have been many reports about factors involved in the severity and prognosis of toxicity. The aim of this study was to evaluate the relationship between the serum C-reactive protein activity and clinical outcome in acute organophosphate-poisoned patients. METHODS: This was a retrospective cohort study conducted from January 2007 to February 2012. Using a multivariate logistic analysis, data on the total population was retrospectively analyzed for association with mortality. The difference in C-reactive protein value between initial and follow-up after 24 hours (D-CRP) was compared in survivors and non-survivors. The D-CRP, APACHE (Acute Physiology and Chronic Health Evaluation) II scoring system and SOFA (Sequential Organ Failure Assessment) score were compared by analyzing receiver operating characteristic (ROC) curves. RESULTS: Among the 96 subjects, 74 survived and 22 died. In the total population, age, BUN, creatinine, APACHE II and SOFA score, MAP, GCS, hematocrit, respiratory rate, albumin, cholinesterase, and the difference in C-reactive protein value between initial and follow-up after 24 hours (D-CRP) were found to be associated with mortality. The fatality rate of organophosphate poisoning was 22.9% and the D-CRP was found to be associated with a significantly higher risk of death in a multiple logistic regression (Odds ratio = 1.178, 95% CI = 1.049-1.322, p = 0.006). CONCLUSION: The initial serum C-reactive protein and acetylcholinesterase were not found to be associated with the severity of acute organophosphate poisoning. However, the difference in C-reactive protein value between initial and follow-up after 24 hours (D-CRP) was associated with mortality in the total population of patients with acute organophosphate poisoning.

Clinical features in adult patients with in-hospital cardiovascular events with confirmed 2009 Influenza A (H1N1) virus infection: comparison with those without in-hospital cardiovascular events.

BACKGROUND: Comprehensive data regarding in-hospital cardiovascular events of adults with confirmed 2009 influenza A (H1N1) (2009 H1N1) infections are limited. The aim of this study was to determine the clinical characteristics, laboratory parameters, and electrocardiographic (ECG) findings for adults with 2009 H1N1 infections and to assess the differences in these parameters among adult patients with and without in-hospital cardiovascular events. METHODS: Seventy-one patients were enrolled from the 2009 H1N1 registry database (our hospital registry of confirmed 2009 H1N1 infection during the year 2009) and divided according to the presence of in-hospital cardiovascular events. Six patients had cardiovascular events (CV group) and 65 did not (NCV group). RESULTS: The CV group was more likely to be old (p = 0.023). Regarding co-morbidities, underlying coronary heart disease (p = 0.001), congestive heart failure (p = 0.001), diabetes (p = 0.001), and hypertension (p = 0.014) had significant influences on cardiovascular events. The CV group was also more likely to have chest pain (p = 0.034), dyspnea (p = 0.045), higher leukocyte count (p = 0.014), higher C-reactive protein (p = 0.010), higher glucose level (p = 0.001), and higher N-terminal probrain natriuretic peptide level (p = 0.010) than the NCV group. In addition, the CV group had a significantly higher in-hospital mortality rate (p = 0.010) and cardiac mortality rate (p = 0.001) than the NCV group. However, there were no significant differences in ECG findings between the two groups. CONCLUSION: Our study demonstrated that the CV group had higher in-hospital and cardiac mortality rates than the NCV group. A meticulous therapeutic approach should be considered for elderly patients with 2009 H1N1 infections having coronary heart disease, congestive heart failure, diabetes, hypertension, and high levels of leukocyte count, hs-CRP, glucose, and NT-proBNP at the time of admission.

Arterial lactate as a predictor of mortality in emergency department patients with paraquat intoxication.

CONTEXT: Plasma paraquat concentration is recognized as the best prognostic indicator in patients with acute paraquat poisoning, but it cannot be measured in many hospitals due to limited medical resources. By contrast, arterial lactate is easily obtainable, even in local hospitals. OBJECTIVE: To evaluate whether initial arterial lactate concentration is a good predictor of mortality in patients with acute paraquat poisoning. MATERIALS AND METHODS: A total of 272 patients with acute paraquat poisoning were admitted to the emergency department of Samsung Changwon Hospital from January 2005 to January 2011. Initial arterial lactate in the emergency department was compared in survivors and non-survivors. Initial arterial lactate and the Acute Physiology and Chronic Health Evaluation II (APACHE II) score system were compared by analyzing receiver operating characteristic (ROC) curves. RESULTS: The overall rate of mortality was calculated to be 81.6%; 222 out of 272 patients died. The arterial lactate was higher in non-survivors (8.30 ± 4.04 mmol/L) than survivors (2.81 ± 1.95 mmol/L) (p < 0.001). The arterial lactate was found to be associated with a significantly higher risk of death in a multiple logistic regression (odds ratio (OR) = 7.02, 95% confidence interval = 2.06-23.91, p = 0.002). For the ROC curve analysis, the arterial lactate had an area of 0.886 and the cut-off concentration was 4.4 mmol/L (sensitivity 82%, specificity 88%, the best Youden index was 0.7). The APACHE II score system had an area of 0.859 and the cut off was 9 (sensitivity 75%, specificity 84%, and the best Youden index was 0.59). DISCUSSION AND CONCLUSION: The arterial lactate had a good predictive power in evaluating the prognosis of patients with acute paraquat poisoning. In the case of hospitals without facilities to test plasma paraquat concentration, measurement of the arterial lactate may be a simple and practical tool for assessing the severity of paraquat poisoning.

Comparison of the Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II scoring system, and Trauma and Injury Severity Score method for predicting the outcomes of intensive care unit trauma patients.

PURPOSE: The aim of this study was to assess the ability of the Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system, and Trauma and Injury Severity Score (TRISS) method to predict group mortality for intensive care unit (ICU) trauma patients. METHODS: The medical records of 706 consecutive major trauma patients admitted to the ICU of Samsung Changwon Hospital from May 2006 to April 2010 were retrospectively examined. The SOFA and the APACHE II scores were calculated based on data from the first 24 hours of ICU admission, and the TRISS was calculated using initial laboratory data from the emergency department and operative data. The probability of death was calculated for each patient based on the SOFA score, APACHE II score, and TRISS equations. The ability to predict group mortality for the SOFA score, APACHE II score, and TRISS method was assessed by using 2-by-2 decision matrices and receiver operating characteristic curve analysis and calibration analysis. RESULTS: In 2-by-2 decision matrices with a decision criterion of 0.5, the sensitivities, specificities, and accuracies were 74.1%, 97.1%, and 92.4%, respectively, for the SOFA score; 58.5%, 99.6%, and 91.1%, respectively, for the APACHE II scoring system; and 52.4%, 94.8%, and 86.0%, respectively, for the TRISS method. In the receiver operating characteristic curve analysis, the areas under the curve for the SOFA score, APACHE II scoring system, and TRISS method were 0.953, 0.950, and 0.922, respectively. CONCLUSION: The results from the present study showed that the SOFA score was not different from APACHE II scoring system and TRISS in predicting the outcomes for ICU trauma patients. However, the method for calculating SOFA scores is easier and simpler than APACHE II and TRISS.